T.R.N.C

NEAR EAST UNIVERSITY

INSTITUTE OF HEALTH SCIENCES

CRITICAL CARE NURSES’ KNOWLEDGE ON

PREVENTION OF VENTILATOR ASSOCIATED

PNEUMONIA AND BARRIERS OF ADHERENCE TO

PREVENTIVE MEASURES

MOATH ALKHAZALI

In Partial Fulfillment of the Requirements for the

Degree of

Master of Nursing (Emergency Nursing)

NICOSIA 2017

T.R.N.C

NEAR EAST UNIVERSITY

INSTITUTE OF HEALTH SCIENCES T.R.N.C

CRITICAL CARE NURSES’ KNOWLEDGE ON

PREVENTION OF VENTILATOR ASSOCIATED

PNEUMONIA AND BARRIERS OF ADHERENCE TO

PREVENTIVE MEASURES

MOATH ALKHAZALI

Master of Nursing (Emergency Nursing)

Advisor:

Prof. Dr. Nurhan Bayraktar

NICOSIA 2017

I

APPROVAL

The Directorate of Graduate School of Health Sciences, This study has been

accepted by the thesis committee in nursing program as a master of

emergency nursing thesis.

Thesis Committee:

Chairman: Assoc. Prof. Ümran DAL YILMAZ (Near East University).

Member: Professor, Nurhan BAYRAKTAR (Near East University).

Member: Assist. Prof. Gülten SUCU DAĞ (Eastern Mediterranean University).

Approval:

According to the relevant article of the Near East University Postgraduate

Study-Education and Examination Regulation, this thesis has been approved

by the above-Mentioned members of the thesis committee and the decision of

the board of Directors of the Institute.

Professor, K. Hüsnü Can BAŞER

Director of Graduate Institute of Health Sciences

II

DECLARATION

I hereby declare that the work in this thesis entitled “Critical Care Nurses’ Knowledge

on Prevention of Ventilator Associated Pneumonia and Barriers of Adherence to

Preventive Measures.” is the study of my own research efforts undertaken under the

supervision of Prof. Dr. Nurhan Bayraktar.

My deepest thanks to Prof. Dr. Nurhan Bayraktar, my supervisor, for her expertise,

on-going support and mentorship during my research.

A special thank you to my committee members, Assoc. Prof. Ümran DAL YILMAZ,

Assist. Prof. Gülten SUCU DAĞ and Assist. Prof. Burcu TOTUR DİKMEN for

their invaluable feedback and support with this thesis.

I express my profound gratitude to my parents for their support, constant

encouragement through all my years of study and through the process of researching

and writing the thesis.

Thank you as well to my colleagues and dearest friends for all your encouragement and

guidance.

III

Critical Care Nurses’ Knowledge on Prevention of Ventilator

Associated Pneumonia and Barriers of Adherence to Preventive

Measures

ABSTRACT

Introduction: Ventilator associated pneumonia (VAP) is the most prevalent infection

in intensive care units (ICUs), with the highest mortality rate among nosocomial

infections. There is a need to increase knowledge and awareness of nurses on VAP risks

and prevention to avoid complications.

Objectives: The aim of the study is determination of the knowledge on prevention of

ventilator associated pneumonia and barriers of adherence to preventive measures of

the critical care nurses.

Methods: The study was performed as descriptive design on critical care nurses (n =

193) in two hospitals of Jordan. A questionnaire that was developed by the researchers

was used as data collection tool. Data were collected in June-July 2017. Descriptive

statistics and Pearson Chi-Square tests were used in analysis of the data.

Results: Results of the present study showed high level of knowledge on general VAP

knowledge and VAP prevention. Regarding to barriers of nurses to adherence to VAP

prevention guidelines, there were high rates of “sometimes” and “always” and low rates

of the “never” answers. The main self-reported barriers towards evidence-based

guidelines were Shortage of staff in the ICU, Lack of time and educational programs

on VAP.

Conclusions: Continuous educational programs in order to enhance the knowledge and

practices of the nurses on VAP, and national and institutional regulations to prevent

barriers of VAP prevention were recommended.

Keywords: Critical care nurses, VAP, Prevention, Knowledge, Barriers.

IV

List of content

APPROVAL .............................................................................................................. I

DECLARATION ...................................................................................................... II

ABSTRACT ..............................................................................................................3

List of Abbreviations ..................................................................................................7

1. INTRODUCTION ..................................................................................................1

1.1 Problem Definition ..........................................................................................1

1.2 Aim of the Study..............................................................................................4

2. BACKGROUND ....................................................................................................4

2.1. Definition ........................................................................................................4

2.2. Risk Factors for VAP .....................................................................................5

2.3. Prevention of VAP .........................................................................................6

2.4. Nurses’ Roles and Barriers in VAP Prevention ............................................8

3. METHODOLOGY ............................................................................................... 10

3.1 Study Design: ................................................................................................ 10

3.2 Study Setting: ................................................................................................ 10

3.3 Sample Selection: .......................................................................................... 10

3.4 Study Tools:................................................................................................... 10

3.5 Pilot Study: .................................................................................................... 11

3.6 Data Collection: ............................................................................................. 11

3.7 Ethical Aspect: .............................................................................................. 11

3.8 Analysis of Data: ........................................................................................... 11

4. RESULTS ............................................................................................................ 12

5. DISCUSSION ...................................................................................................... 25

6. CONCLUSION .................................................................................................... 29

7. FINDINGS AND RECOMMENDATIONS.......................................................... 30

7.1. Findings ........................................................................................................ 30

7.2 Recommendations ........................................................................................ 31

8. REFERENCES ..................................................................................................... 32

V

List of Tables

Table 4.1 Descriptive Characteristics of the Nurses (N= 193) .................................12

Table 4. 2 Characteristics of the Nurses on VAP Education (N= 193) ......................13

Table 4. 3 Nurses General Knowledge on VAP (N=193).........................................15

Table 4.4 Nurses’ Knowledge on Prevention of VAP (N=193) ...............................16

Table 4. 5 Barriers of Nurses to Adherence to VAP Prevention Guidelines (N=193)

.................................................................................................................................18

Table 4. 6 Comparison of Nurses` Educational Degree, Years of ICU Experience and

Previous VAP Education with General Knowledge on VAP (N=193) .......................19

Table 4.7 Comparison of Nurses` Educational Degree, Years of ICU Experience and

Previous VAP Education with Knowledge on prevention of VAP (N=193) ..............20

Table 4. 8 Comparison of Nurses` Educational Degree, Years of ICU Experience and

Previous VAP Education with Nurses ` Barriers to Adherence to VAP Prevention

Guidelines (N=193) ..................................................................................................24

VI

List of Appendix

APPENDIX 1 Critical Care Nurses’ Knowledge on Prevention of Ventilator

Associated Pneumonia (VAP) and Barriers of Adherence to Preventive Measures

.................................................................................................................................41

APPENDIX 2 King Abdullah University Hospital Ethical Approval Form .......45

APPENDIX 3 Islamic Hospital Ethical Approval Form ......................................46

APPENDIX 4 Ethical Approval Near East institutional Reviews Board ............47

APPENDIX 5 Informed Consent Form For Adults .............................................48

VII

List of Abbreviations

Hospital Acquired Infections HAI

Centers For Disease Control And Prevention CDC

Ventilator Associated Pneumonia VAP

Intensive Care Units ICUs

Endotracheal Tube ETT

Mechanical Ventilator MV

Acute Respiratory Distress Syndrome ARDS

Institute For Healthcare Improvement IHI

Noninvasive Positive Pressure Ventilation NIPPV

Ventilator Associated Event VAE

Deep Vein Thrombosis DVT

Spontaneous Awakening Trials SATs

Spontaneous Breathing Trials SBTs

Head Of Bed HOB

Polyvinyl Chloride PVC

Nurse Assistants RAs

Registered Nurses RNs

1

1. INTRODUCTION

1.1 Problem Definition

Hospital acquired infections (HAI), also known as nosocomial infections

are important problem all over the world. This term is used for any disease acquired by

patient under medical care (Krishna, 2014). Recently, a new term, “healthcare

associated infections” is used for the type of infections caused by prolonged hospital

stay and it accounts for a major risk factor for serious health issues leading to

death (Brusaferro et al, 2015). About 75% of the burden of these infections is present

in developing countries (Obiero et al, 2015). The U.S.A Centers for Disease Control

and Prevention (CDC, 2015) estimates that HAIs in American hospitals account for

approximately 1.7 million infections and 99,000 associated deaths each year. Based on

a study of a large sample of the U.S.A. acute care hospitals, on any given day,

approximately 1 in 25 hospital patients has at least one healthcare-associated infection

(CDC, 2015). In the U.S.A. the direct costs associated with HAIs have been estimated

at >$30 billion annually (Cusumano-Towner et al, 2013). In some countries of the

Eastern Mediterranean Region (Morocco, Jordan and Tunisia), prevalence studies on

the rates of health care-associated infections conducted between 2004 and 2008 have

found them to be between 12% and 18% ( Allegranzi, 2010). There are many type of

hospital acquired infections, but the most common health care associated infections are

ventilator associated pneumonia (VAP), urinary tract infection (catheter associated),

bloodstream infection (associated with the use of intravascular device) and surgical-site

infection.

VAP is the most prevalent infection in intensive care units (ICUs), with the

highest mortality rate among nosocomial infections (Albertos et al, 2011). It accounts

for 25 % of all types of intensive care unit acquired infections (Balkhy, 2014). In the

United States, the incidence is 3-5 cases per 1,000 ventilator-days (Spalding et al,

2017). A recent prospective surveillance study found that VAP prevalence was 15.6%

globally (13.5% in the USA, 19.4% in Europe, 13.8% in Latin America and 16.0% in

Asia Pacific) (Kollef, 2014).

2

VAP results in a significant increase in the cost of care (van Oort et al 2017),

prolonged hospitalization (Kandeel et al 2012), an extended number of days in need of

the mechanical ventilator (Khan et al 2017), and a significant increase in the rate of

mortality (Porhomayon et al 2017). The mortality rate of this infection ranges from 20

to 70% (Azab et al 2013, Kandeel et al 2012).

VAP is an infection of the lung that occurs 48 hours after insertion of an

endotracheal tube (Rodrigues et al, 2017). The principal factor for the development of

VAP is the presence of an endotracheal tube (Zolfaghari et al, 2011). A ventilator is a

device that is used to improve patient breathe by giving oxygen via tube placed in the

nose or mouth, or through a hole in the front of the neck (tracheostomy). An infection

occur when the germs enter via tube and reach to patient`s lung and caused lung

infection (alveoli infection). These tubes interfere with the normal protective upper

airway reflexes, prevent effective coughing, and encourage micro aspiration of

contaminated pharyngeal contents (He et al, 2014).

Many risk factors cause to ventilator associated pneumonia (VAP). The risk

factors for VAP can be divided into 3 categories: host related (such as acute respiratory

distress syndrome) device related (such as the ventilator circuit) and personnel related

(such asfailure to wash hands) (Casado et al, 2011). In a study, re-intubation was found

as a risk factor for VAP in patients who had ever undergone cardiac surgery (He et al,

2014). It is important to control modifiable factors.

There is no single method to prevent VAP, but multiple non-pharmacological

and pharmacological interventions exist that could reduce the incidence and severity of

VAP (Lim et al, 2015; Shitrit et al, 2015). CDC ( 2012) provides guidelines and tools

to the healthcare community to help end ventilator-associated pneumonia and resources

to help the public understand these infections and take measures to safeguard their own

health when possible (CDC, Health Healthcare-associated Infections Update Guideline

2012). There are a lot of recommendations to prevent VAP like head elevated 30-45

and good oral hygiene, selective oral or digestive decontamination (Liberati et al, 2009),

and facilitate early mobility (Lord et al, 2013; Needham et al, 2010). According to the

previously published studies, the implementation of a VAP prevention bundle had been

proven to be efficacious in reduction of VAP rates (Lim et al, 2015; Shitrit et al, 2015).

3

Quality nursing care based on evidence-based strategies is efficient ways of

preventing VAP in intensive care units (ICUs) (Akın, 2014). Nurses play an important

role to prevent VAP and improve the patient`s outcome if they are well-educated. The

application of knowledge to the care of critically ill patients is a hallmark of

professional nursing practice. Many non-pharmacological evidence-based strategies

aimed at preventing VAP can be seen as part of basic and routine nursing care, a direct

responsibility of the bedside intensive care nurse and can easily be instituted at minimal

costs; neglecting any of these could put the patient at risk of infection (Llauradó et al,

2011).

There are many barriers to ventilator associated pneumonia (VAP) prevention

and practice among nurses. The most of these barriers is including shortage of

resources, insufficient compliance with infection-control standards (AL-Rawajfah et al,

2014) and inadequate knowledge about VAP among health care providers (Hassan et

al, 2016). Insufficient knowledge of the nurses ‘about the guidelines results in a lack of

competence, and is considered a barrier to adherence (Yeganeh et al, 2016; Ha et al,

2016).

Determination of the knowledge on prevention of ventilator associated

pneumonia and barriers of adherence to preventive measures of the critical care nurses

may be useful in improving their awareness, practices and preventing this important

problem. However a study was not found in the Jordan about this subject and studies.

4

1.2 Aim of the Study

The aim of the study is determination of the knowledge on prevention of ventilator

associated pneumonia and barriers of adherence to preventive measures of the critical

care nurses. Study questions include followings:

What is the knowledge on prevention of ventilator associated pneumonia of

critical care nurses?

What are the barriers of adherence to preventive measures of ventilator

associated pneumonia of the critical care nurses?

Is there any difference between descriptive characteristics, and knowledge on

prevention of ventilator associated pneumonia and barriers of adherence to

preventive measures of the critical care nurses?

2. BACKGROUND

2.1. Definition

Ventilator associated pneumonia (VAP) is defined as a type of pneumonia that

is an acquired from the hospital in a patient who connected to mechanical ventilator

support via tracheostomy or endotracheal tube for more than 48 hours with signs and

symptoms indicate to pneumonia. VAP is considered the most common hospital

acquired infection. VAP characterized by new or progressive pulmonary infiltrate and

one or more of the following findings: decrease in oxygen saturation and tidal volume;

increase in respiratory rate, white blood cells (leukocytosis) and body temperature

(fever); and purulent tracheobronchial secretions. The studies have reported that 27%

of intubated patients develop VAP during hospitalization (Spalding et al 2017).

Intubation is an invasive procedure, and puts patients at risk in developing a HAI

(Mietto et al, 2013). The process of intubation decreases the body’s natural response to

infection by disrupting the ability to initiate a cough or gag reflex that assists in

expelling secretions, as a result, secretions settle around the posterior portion of the

pharynx and can eventually lead to micro-aspiration (Sedwick et al, 2012). Proper

inflation of the endotracheal tube (ETT) cuff does not prevent micro-aspiration, because

there is a small opening that allows leakage of the secretions to travel (Mietto et al,

2013).

5

2.2. Risk Factors for VAP

There are many risk factors for VAP. Although any patient connected to

mechanical ventilator (MV) for more than 48 hours is at risk for VAP; host related,

device related, and personnel related factors are considered as categories of VAP risk

factors (Casado et al, 2011).

Host related factors include the problems which previously exist such as:

immune deficiency, acute respiratory distress syndrome (ARDS), and chronic

obstructive lung disease. There are other host-related factors including patients’ body

positioning, level of consciousness, number of intubations, and medications, including

sedative agents and antibiotics (Fathy et al, 2013).

Device related risk factors include, use the nasal route to place endotracheal

tubes, un-clean ventilator circuit, and un-cuffed endotracheal tubes. Insufficient cuff

pressure leads to aspiration of oropharyngeal contents (Sole et al, 2011).

Lack of stuff hand washing due to cross-contamination from patient to another

and it is the most personnel-related risk factor for VAP. Failure to wash hands and

change gloves between contaminated patients has been associated with an increased

incidence of VAP (Labeau et al, 2007).

The risk factors for VAP differ between adults and children. The duration of

mechanical ventilation is a risk for both groups, but the results of studies in children

have differed somewhat from the results of studies in adults (Casado et al, 2011).

Primarily, unlike adults, children have developmental and physiological differences for

a wide range of ages. Age is also a factor in immunity, so younger or preterm infants

are more likely than older children or adults to experience infection and to have more

frequent episodes of infection (Casado et al, 2011).

6

2.3. Prevention of VAP

VAP prevention is performed through pharmacological and non-

pharmacological measures that mainly focus on modifiable risk factors. The Center for

Disease Control and Prevention (CDC) and Institute for Healthcare Improvement (IHI)

have introduced recommendations (Andrews et al, 2013; Munro et al, 2014). There are

many recommendations to prevent VAP:

Avoiding intubation if possible and use noninvasive positive pressure

ventilation (NIPPV) whenever feasible is recommended. NIPPV can be

beneficial for patients with acute hypercarbic or hypoxemic respiratory failure

secondary to chronic obstructive pulmonary disease or cardiogenic congestive

heart failure. NIPPV for these indications may decrease VAP risk, shorten the

duration of mechanical ventilation, decrease length of stay, and lower mortality

rates compared with invasive ventilation (Klompas et al, 2014).

Managing ventilated patients without sedatives whenever possible.

Preferentially use agents and strategies other than benzodiazepines to manage

agitation, such as analgesics for patients in pain, reassurance, antipsychotics,

dexmedetomidine and propofol is recommended. Sedation should be interrupted

once a day (spontaneous awakening trials) for patients without

contraindications. Assessing readiness to extubate once a day (spontaneous

breathing trials) in patients without contraindications is recommended. Pairing

spontaneous breathing trials with spontaneous awakening trials is necessary

(Klompas et al, 2014).

Minimizing pooling of secretions above the endotracheal tube cuff is

recommended (Klompas et al, 2014).

Changing the ventilator circuit only if visibly soiled or malfunctioning is

recommended. Changing the ventilator circuit as needed rather than on a fixed

schedule has no impact on VAP rates or patient outcomes but decreases costs

(Klompas et al, 2014).

7

Elevating the head of the bed to 30–45 degree (Keeley, 2007); Head of bed

elevated between 30 to 45 degree is a simple nursing measure to reduce VAP;

Keeping the head of bed elevated has been shown to help prevent aspiration of

gastric contents and secretions (Klompas et al, 2014; Schallom et al, 2015).

Providing early exercise and mobilization: Early exercise and mobilization

speed extubation, decrease length of stay, and increase the rate of return to

independent function (Klompas et al, 2014).

Prophylactic probiotics: Four meta-analyses of randomized controlled trials

have found an association between probiotics and lower VAP rates (Barraud et

al, 2013; Siempos et al, 2010).

Good oral hygiene: Oral care may seem to be a simple task, but it can be

challenging to implement. Swabbing a patient’s mouth with an antiseptic mouth

wash has been recommended for comfort, but recent studies have demonstrated

that oral care with an antiseptic has also reduced the risk for Ventilator

Associated Event (Garcia et al, 2009). Chlorhexidine is a broad spectrum

antiseptic agent (gram-positive, gram-negative, and yeast) which is easy to use,

safe, and cost-effective. Additionally, chlorhexidine's slow release properties

maintain antimicrobial activity up to 12h (Osman, 2014; Williams al, 2012).

Use of mechanical tooth brushing (Alhazzani et al, 2013; Yao et al, 2011).

Saline instillation before tracheal suctioning (Caruso et al, 2009) is

recommended. One randomized trial in oncology patients found that saline

instillation before tracheal suctioning lowered the rate of microbiologically

confirmed VAP but had no impact on clinical VAP rates or patient outcomes

(Klompas et al, 2014).

Automated control of endotracheal tube cuff pressure between (20 to 30 cm) is

recommended (Nseir et al, 2011; Valencia et al, 2007).

Endotracheal tubes with ultrathin polyurethane cuff membranes of 7 mm only

have been introduced to prevent the formation of folds within the cuff and fluid

and air leakage. These devices have shown to reduce the frequency of early

postoperative pneumonia in cardiac surgical patients (Poelaert et al, 2014).

8

The development by the Institute of Healthcare Improvement (IHI) of VAP

“bundles”—a series of performance measures associated with reducing the incidence

of VAP—was an important step in the overall evolution of process measures and

accountability for changing clinical behavior and improving the quality of care for

critically ill patients (Resar et al, 2012). The VAP prevention bundle includes: head-of-

bed elevation to 30 to 45 degrees, oral care with chlorhexidine at 0.12 percent, peptic

ulcer disease prophylaxis, deep vein thrombosis (DVT) prophylaxis and ABCDEF

bundle elements (i.e. assess, prevent and manage pain — both spontaneous awakening

trials and breathing trials, choice of analgesia and sedation, delirium assessment,

prevention and management, exercise and early progressive mobility and family

engagement and empowerment) (Frimppong et al, 2014; Institute for Healthcare

Improvement, 2012).

2.4. Nurses’ Roles and Barriers in VAP Prevention

Nurses are the most contact with patients and they playing a main role to prevent

VAP and increase the positive patient`s outcome if the nurse receive well-educated.

The nurses’ main practice roles to prevent VAP include:

Assessing readiness to extubate daily through combined spontaneous awakening

trials (SATs: sedation interruption/minimization) and spontaneous breathing trials

(SBTs), unless clinically contraindicated (Balas et al, 2014; Yang et al, 2014).

Elevating the head of bed (HOB) to 30 to 45 degree unless clinically contraindicated

in patients receiving mechanical ventilation, as well as patients at high risk for

aspiration (Alexiou et al, 2009).

Utilizing endotracheal tubes with subglottic secretion drainage ports for patients

expected to require greater than 48 or 72 hours of mechanical ventilation (Muscedere

et al, 2011).

Collaborating to identify patients where implementation of noninvasive positive

pressure ventilation (NIPPV) may be appropriate to prevent the need for intubation

(Burns et al, 2013).

Good hand hygiene and oral care and change gloves between the patients.

Changing the ventilator circuit only if visibly soiled or malfunctioning (Lorente et

al, 2004).

Using sterilize equipment and aseptic technique.

9

Adherence the nurses to prevention measures is playing important role to reduce

probability of VAP because the nurses is most connected with the patients. However,

there are a lot of nursing practice barriers among VAP prevention. In the same line the

study conducted by (Jordan et al., 2014) that notices the main barriers to using VAP

guidelines are lack of VAP courses and nursing shortages and lack of time was

identified as another barrier. In another hand, a survey study revealed poor information

provided to nurses regarding current guidelines and the lack of instruction in VAP

prevention methods in nursing schools (Jansson et al., 2013). The lack of knowledge

may be a barrier towards adherence to evidence-based guidelines (El-Khatib et al.,

2010). Study that published in (Aloush, 2017) revealed Jordanian nursing students had

poor knowledge.

Several studies implicated that education, guidelines as well as ventilator

bundles and instruments should be developed and updated to improve infection control

(Jansson et al. 2013). A study that held at Jordan's nursing schools with (Al-Hussami et

al 2013) recommended that the nursing curriculum should include additional emphasis

on practice as a means to help translate theory into clinical behavior. There are many

educational programs that were linked to significant improvements in the overall

adherence to VAP evidence-based strategies and a significant decrease in VAP rates.

Educational programs consisted of self-study modules (Abbot, 2006), repeated lectures

(Bloos, 2009), teaching materials (Morris, 2011), multidisciplinary education meetings

(Morris, 2011) and reminders, such as e-mails (Abbot, 2006), posters (Morris, 2011)

and visual aids, Also reported that the clinical outcomes of educational programs was

decreasing in the incidence of VAP (Morris, 2011).

11

3. METHODOLOGY

3.1 Study Design:

The study was planned as descriptive design.

3.2 Study Setting:

The study was conducted at the King Abdullah University Hospital and Islamic

Hospital Jordan. The King Abdullah University Hospital is the largest and leading

university of Jordan which is located in northern part of Jordan in Irbid city. The

hospital consists of 15 floors and 683 beds,12 operating theatres, 78-bed Intensive Care

Unit (divided into medical, surgical, pediatric, neonatal, cardiac and burn) and has

hospital protocol for prevention the VAP is (bundle VAP protocol). Islamic hospital

has 300 beds, 8 operating theatres and 25 intensive care bed, and hospital protocol for

prevention the VAP.

3.3 Sample Selection:

The study was performed on the registered nurses who work in ICU departments

of the King Abdullah University Hospital and Islamic Hospital. A total of 132 nurses

work in ICU in the King Abdullah University Hospital and 61 nurses in ICU in Islamic

Hospital (Total 193 nurses). There was no sample selection method. Total 193

voluntary nurses who work in ICU clinics was composed the sample of the study.

3.4 Study Tools: A questionnaire that was developed by the researchers on the basis of

the literature was used as data collection tool in this study (Yaseen et al

2015); (Jansson, et al 2013) (Appendix 1). The first section was regarding to

demographics characteristics of the nurses and included 10 questions. The

second section consisted 30 questions regarding knowledge of nurses on

VAP prevention with “True / False / I don’t know” choices. The last section

consisted 8 questions regarding the barriers to adherence to VAP prevention

measures with “Always / Sometimes / Never” choices. Since all of the nurses

in the hospital can speak English, the questionnaire was prepared as English.

11

3.5 Pilot Study:

A pilot study was performed on ten nurses after approval from the Near East

Institutional Reviews Board (IRB) and King Abdullah University Hospital and Islamic

Hospital. After the pilot study, revision was not necessary and the nurses who included

in pilot study were added to main sample.

3.6 Data Collection:

Data was collected using a questionnaire from 20th of June to 10th of July 2017.

The questionnaires were administered by researchers on nurses while they are on the

wards or clinics during duty shift with self-completion method. Completion of the

questionnaire took almost 20 minutes.

3.7 Ethical Aspect:

Ethical approval was obtained from the Near East Institutional Reviews Board

(IRB) of King Abdullah University Hospital and Islamic Hospital of Jordon (Appendix

2& Appendix 3). In addition, informed consent from the nurses and organizational

permission were obtained (Appendix 4).

3.8 Analysis of Data:

Statistical Package of Social Sciences (SPSS) software version 20.0 was used

to analyze the collected data. The methods used to analyze the data include an analysis

of descriptive statistic variables such as frequency and percentages for the categorical

variables. “True / False’’ variables were used in evaluations of knowledge questions,

the comparison were between only always scale and educational degree, years of nurses

experience and previous VAP education of the nurses barriers. The person chi-squire

test was used in comparisons. When finding statistic was significant, the chosen level

of significance is p < 0.05.

12

4. Results

Table 4.1 Descriptive Characteristics of the Nurses (N= 193)

Description of characteristics of the nurses is shown in Table 4.1. A total of the nurses

of participants in this study 193, the mean of ages of the participants were 28.4 and the

26-30 group of age was the most frequent (56.5%). Females were the majority of the

Participants (60.1%). Most of the participants have bachelor's degree (89.7%). Majority

of the nurses have experience less than five years as a registered nurses (60.1%). The

number of beds were approximately the same for the groups where the percent of

participants working in ICU beds <=12 beds was 50.3%.

% N Descriptive characteristics

Age (Mean :28.4)

22.8 44 <=25 years

56.5 109 26-30 years

20.7 40 >=31

Gender

39.9 77 Male

60.1 116 Female

Educational degree

89.7 173 Bachelor`s

10.3 20 Master degree

Working experience in the ICU

60.1 116 <=5 years

34.7 67 6-10 years

5.2 10 >=11

Number of beds in ICU

50.3 97 <=12 beds

49.7 96 >=13 beds

13

Table 4. 2 Characteristics of the Nurses on VAP Education (N= 193)

*Percentage were calculated based on N=137

% N Characteristics on VAP Education

Previous VAP education

71.0 137 Yes

29.0 56 No

Educational resource (N=137)*

15.4 21 School

34.3 47 Courses

13.1 18 Web resources

23.4 32 In-service education

2.9 4 Congress\Conferences

10.9 15 Other

Opinions about quality of the VAP Education (N=137)*

10.2 14 Excellent

19.0 26 Very good

57.7 79 Good

10.9 15 Fair

2.2 3 Poor

Need for education on VAP

79.8 154 Yes

20.2 39 No

Using Hospital protocol on prevention of VAP

90.7 175 Yes

9.3 18 No

14

The description of characteristics of the nurses on VAP education is shown in Table

4.2. The majority of the nurses had received VAP education (71.0%). There are six

categories of educational recourse which the participants had received VAP education.

The highest percent was the courses as educational resource (34.3%). Most frequently

stated opinion by the nurses on quality of VAP education was “good” (57.7%). The

majority of nurses need for education on VAP (79.8%) and there are hospital protocols

on prevention of VAP (90.7%).

15

Table 4. 3 Nurses General Knowledge on VAP (N=193)

*(T) = True statement, (F) = False statement

Table 4.3 shows nurses` general knowledge on VAP. It was found that; majority of the nurses

had correct answers in majority of the items (5 of 6 items). The most frequently known items

were "Continuous education to ICU nurses on prevention of nosocomial infection is

associated with decreased rates of VAP" (T) (88.6%), "VAP is cause of highest mortality rate

among nosocomial infections" (T) (86.5%) and “The Ventilator Associated Pneumonia

(VAP) is pneumonia that occurs > or equal 48 hours after endotracheal intubation” (81.3%)

respectively. Percentages of the correct answers of the nurses were close in item "Automated

control of endotracheal tube cuff pressure is important because it decrease the risk for VAP"

(T) (The correct answers: 53.4% and the wrong\ I don`t know answers: 46.6%).

Statements on VAP

T\F

Correct answer Wrong \I don’t

know answer

N % N %

The Ventilator Associated Pneumonia (VAP) is

pneumonia that occurs > or equal 48 hours after

endotracheal intubation.

T 157 81.3 36 18.7

VAP is cause of highest mortality rate among

nosocomial infections. T 167 86.5 26 13.5

VAP is the most prevalent infection in intensive care

units. T 145 75.1 48 24.8

Automated control of endotracheal tube cuff

pressure is important because it decreases the risk

for VAP.

T 103 53.4 90 46.6

Over feeding a ventilated patient is associated with

increased the risk for VAP. T 150 77.7 43 22.3

Continuous education to ICU nurses on prevention

of nosocomial infection is associated with decreased

rates of VAP.

T 171 88.6 22 11.4

16

Table 4 .4 Nurses’ Knowledge on Prevention of VAP (N=193)

Statements on Prevention of VAP

T\F Correct answer

Wrong /I don’t

know answer

N % N %

If possible, intubation should be avoided to prevent

VAP. T 141 73.1 52 26.9

Whenever feasible, noninvasive positive pressure

ventilation should be used to prevent VAP T 102 52.8 91 47.1

It is necessary to manage patients without sedation

whenever possible to prevent VAP T 121 62.7 72 37.3

Benzodiazepines should always be preferred to

manage agitation F 83 43.0 110 57.0

Sedation should be interrupted daily to prevent

VAP T 124 64.2 69 35.8

It is necessary to assess readiness to extubate of the

patient daily to prevent VAP T 164 85.0 29 15

Pairing spontaneous breathing trials with

spontaneous awakening trials is not necessary F 69 35.8 124 64.3

Minimizing pooling of secretions above the

endotracheal tube cuff is necessary to prevent VAP T 133 68.9 60 31.1

Changing the ventilator circuit regularly is

necessary to prevent VAP F 146 75.6 47 24.3

Elevating the head of the bed to 30–45 is important

in prevention of VAP T 173 89.6 20 10.4

Early exercise and mobilization may increase the

possibility of VAP F 103 53.4 90 46.7

Regular oral care with chlorhexidine is necessary

to prevent VAP T 170 88.1 23 11.9

Proper sterilization and disinfection of respiratory

care equipment is important to prevent VAP T 169 87.6 24 12.4

Oral route is recommended for endotracheal

intubation to prevent VAP T 125 64.8 68 35.2

Prophylactic probiotics may be useful to prevent

VAP T 139 72.0 54 27.9

Ultrathin polyurethane endotracheal tube cuffs

may lower VAP rates T 71 36.8 122 63.2

Saline instillation before tracheal suctioning may

cause to VAP F 120 62.2 73 37.8

Mechanical tooth brushing may be useful in

prevention of VAP T 115 59.6 78 40.4

Closed/in-line endotracheal suctioning reduce the

risk of VAP F 143 74.1 50 25.9

Kinetic beds reduce the risk of VAP and

recommended F 126 65.3 67 34.8

Adequate hand hygiene between patients and

change gloves is important to prevent the VAP T 170 88.1 23 11.9

17

Prone positioning intermittently may prevent VAP

and recommended F 84 43.5 109 56.5

Using selective oral or digestive decontamination

to reduce risk VAP T 136 70.5 57 29.5

Care bundles may be useful in reducing VAP T 155 80.3 38 19.7

*(T) = True statement, (F) = False statement

Nurses` knowledge on prevention of VAP is shown in table 4.4 (53.6%) the percentage of total

frequency of correct answers and (46.4%) the total of wrong or "I don`t know" answers. The

highest correct answers were in “Elevating the head of the bed to 30–45 degree is important in

prevention of VAP” (89.6%), “Regular oral care with chlorhexidine is necessary to prevent VAP”

(88.1%), “Adequate hand hygiene between patients and change gloves is important to prevent the

VAP” (88.1%), "Proper sterilization and disinfection of respiratory care equipment is important

to prevent VAP " (T) (87.6%), " It is necessary to assess readiness to extubate of the patient daily

to prevent VAP " (T) (85.0%) and “Care bundles may be useful in reducing VAP” (80.3%) items

respectively. Most frequent wrong /I don’t know answers were in “Pairing spontaneous breathing

trials with spontaneous awakening trials is not necessary (64.3%). “Ultrathin polyurethane

endotracheal tube cuffs may lower VAP rates” (63.2%) with wrong answer, and "Prone

positioning intermittently may prevent VAP and recommended" (56.5%) items.

18

Table 4. 5 Barriers of Nurses to Adherence to VAP Prevention Guidelines (N=193)

Table 4.5 shows barriers of nurses to adherence to VAP Prevention Guidelines. It was

determined that, majority of nurse had "sometimes" answer for the barriers nurses to adherence

to VAP prevention guideline. Most frequent "always" answer was "Shortage of staff in the ICU"

(55.4%). Highest “sometimes” answers were “Lack of educational programs on VAP such as in-

service education or courses”, “Lack of time to deliver proper infection control” (55.4%),

“Forgetting to practice the sterile technique” (54.4%) and “Lack of VAP prevention knowledge”

(53.9%) respectively. Low frequencies in majority of the "never" answers were determined and

most frequent "never" answer was "Lack of equipment such as gloves and face masks"(43.5%).

Statements About Barriers

Always

Sometimes

Never

N % N % N %

Lack of VAP prevention knowledge 73 37.8 104 53.9 16 8.3

Lack of educational programs on VAP such as

in-service education or courses 74 38.3 107 55.4 12 6.2

Shortage of staff in the ICU 107 55.4 72 37.3 14 7.3

Lack of equipment such as gloves and face

masks 34 17.6 75 38.9 84 43.5

Lack of written VAP protocol in the hospital 44 22.8 87 45.1 62 32.1

Forgetting to practice the sterile technique 44 22.8 107 55.4 42 21.8

Lack of time to deliver proper infection control 44 22.8 105 54.4 44 22.8

Hospital system insufficiencies 54 28.0 87 45.1 52 26.9

19

General Knowledge on VAP

(Statements)

Educational Degree

P value

Years of ICU Experience

P value

Previous VAP Education

P

value

Bachelor Master <=5 6-10 >=11 Yes No

Correct answer Correct answer Correct answer

N % N % N % N % N % N % N %

The Ventilator Associated Pneumonia

(VAP) is pneumonia that occurs > or equal 48 hours after endotracheal

intubation

142 82.1 15 75.0 0.441 93 80.2 55 82.1 9 90.0 0.732 111 81.0 46 82.1 0.856

VAP is cause of highest mortality rate

among nosocomial infections 148 85.5 19 95.0 0.241 100 86.2 59 88.1 8 80.0 0.775 120 87.6 47 83.9 0.499

VAP is the most prevalent infection in

intensive care units 130 75.1 15 75.0 0.989 83 71.6 52 77.6 10 100. 0.115 111 81.0 34 60.7 0.003

Automated control of endotracheal tube cuff pressure is important because it

decreases the risk for VAP

96 55.5 7 35.0 0.082 67 57.8 36 53.7 0 0.0 0.002 84 61.3 19 33.9 0.001

Over feeding a ventilated patient is

associated with increased the risk for VAP

134 77.5 16 80.0 0.796 90 77.6 55 82.1 5 50 0.75 103 75.2 47 83.9 0.185

Continuous education to ICU nurses on

prevention of nosocomial infection is

associated with decreased rates of VAP

152 87.9 19 95.0 0.342 102 87.9 59 88.1 10 100. 0.507 126 92.0 45 80.4 0.021

Table 4. 6 Comparison of Nurses` Educational Degree, Years of ICU Experience and Previous VAP Education with General Knowledge on VAP

(N=193)

Table 4.6 shows that there were statistically significant differences between correct answers of some items on general knowledge on VAP and years of ICU experience

and previous VAP education. Nurses with <=5 (57.8%) and 6-10 (53.7%) years of experience had higher correct knowledge rates than the >=11 group (0.0) in terms

of “Automated control of endotracheal tube cuff pressure is important because it decreases the risk for VAP” item (P< 0.05). Nurses who had previous VAP education

had higher correct knowledge rates than the other group in terms of “VAP is the most prevalent infection in intensive care units” (81.0%), “Automated control of

endotracheal tube cuff pressure is important because it decreases the risk for VAP” (61.3%) and “Continuous education to ICU nurses on prevention of nosocomial

infection is associated with decreased rates of VAP” (92.0%) items (P< 0.05). However, there wasn’t statistically significant differences in terms of majority of the

items on general knowledge on VAP and educational degree, years of nursing experience and previous VAP education (P>0.05).

21

Knowledge on prevention of VAP

(Statements)

Educational Degree

P value

Years of ICU Experience

P

value

Previous VAP Education

P

value

Bachelor Master <=5 6-10 >=11 Yes No

Correct answer Correct answer Correct answer

N % N % N % N % N % N % N %

If possible, intubation should be

avoided to prevent VAP

124 71.7 17 85.0 0.204 84 72.7 53 79.1 4 40.0 0.033 97 70.8 44 78.6 0.270

Whenever feasible, noninvasive positive pressure ventilation should be

used to prevent VAP

90 52.0 12 60.0 0.499 55 47.4 42 62.7 5 50.0 0.135 73 53.3 29 51.8 0.850

It is necessary to manage patients

without sedation whenever possible to prevent VAP

109 63.0 12 60.0 0.792 73 62.9 42 62.7 6 60.0 0.983 86 62.8 35 62.5 0.972

Benzodiazepines should always be

preferred to manage agitation

79 45.7 4 20.0 0.028 48 41.4 30 44.8 5 50.0 0.814 63 46.0 20 35.7 0.191

Sedation should be interrupted daily

to prevent VAP

111 64.2 13 65.0 0.941 58.1 62.1 46 68.7 6 60 0.642 92 67.2 32 57.1 0.188

It is necessary to assess readiness to

extubate of the patient daily to prevent

VAP

145 83.8 19 95.0 0.185 96 82.8 60 89.6 8 80.0 0.419 119 86.9 27 80.4 0.251

Pairing spontaneous breathing trials

with spontaneous awakening trials is

not necessary

66 38.2 3 15.0 0.041 39 33.6 27 40.3 3 30.0 0.614 52 38.0 17 30.4 0.317

Minimizing pooling of secretions above the endotracheal

tube cuff is necessary to prevent VAP

121 69.9 12 60.0 0.363 74 63.8 52 77.6 7 70.0 0.150 100 73.0 33 58.9 0.055

Table 4.7 Comparison of Nurses` Educational Degree, Years of ICU Experience and Previous VAP Education with Knowledge on prevention of VAP (N=193)

21

Knowledge on prevention of VAP

(Statements)

Educational Degree

P

value

Years of ICU Experience

P

value

Previous VAP Education

P

value

Bachelor Master <=5 6-10 >=11 Yes No

Correct answer Correct answer Correct answer

N % N % N % N % N % N % N %

Changing the ventilator circuit

regularly is necessary to prevent VAP

132 76.3 14 70.0 0.534 83 71.6 57 85.1 6 60.0 0.060 109 79.6 37 66.1 0.048

Elevating the head of the bed to 30–

45 is important in prevention of VAP

155 89.6 18 90.0 0.955 98 84.5 65 97.0 10 100.0 0.015 124 90.5 49 87.5 0.533

Early exercise and mobilization may

increase the possibility of VAP 97 56.1 6 30.0 0.027 68 58.6 30 44.8 5 50.0 0.190 71 51.8 32 57.1 0.502

Regular oral care with chlorhexidine is necessary to prevent VAP

152 87.9 18 90.0 0.780 102 87.9 59 88.1 9 90.0 0.981 126 92.0 44 78.6 0.009

Proper sterilization and disinfection

of respiratory care equipment is

important to prevent VAP

151 87.3 18 90.0 0.727 104 89.7 55 82.1 10 100.0 0.155 120 87.6 49 87.5 0.986

Oral route is recommended for endotracheal intubation to prevent

VAP

113 65.3 12 60.0 0.637 75 64.7 46 68.7 4 40.0 0.209 88 64.2 37 66.1 0.808

Prophylactic probiotics may be useful to prevent VAP

128 74.0 11 55.0 0.073 84 72.4 48 71.6 7 70.0 0.983 100 73.0 39 69.6 0.638

Ultrathin polyurethane endotracheal

tube cuffs may lower VAP rates 59 34.1 12 60.0 0.023 37 31.9 34 50.7 0 0.0 0.02 59 43.1 12 21.4 0.005

4.7 Conti, Comparison of Nurses` Educational Degree, Years of ICU Experience and Previous VAP Education with Knowledge on prevention of

VAP (N=193).

22

Knowledge on prevention of VAP

(Statements)

Educational Degree

P value

Years of ICU Experience

P

value

Previous VAP Education

P

value

Bachelor Master <=5 6-10 >=11 Yes No

Correct answer Correct answer Correct answer

N % N % N % N % N % N % N %

Saline instillation before tracheal

suctioning may cause to VAP

107 61.8 13 65.0 0.783 74 63.8 41 61.2 5 50.0 0.675 88 64.2 32 57.1 0.357

Mechanical tooth brushing may be useful in prevention of VAP

105 60.7 10 50.0 0.356 65 56.0 42 62.7 8 80.0 0.272 87 63.3 28 50.0 0.083

Closed in-line endotracheal suctioning

reduce the risk of VAP

133 76.9 10 50.0 0.009 85 73.3 52 77.6 6 60.0 0.471 108 78.8 35 62.5 0.019

Kinetic beds reduce the risk of VAP

and recommended

111 64.2 15 75.0 0.335 78 67.2 47 70.1 1 10.0 0.001 92 67.2 34 60.7 0.394

Adequate hand hygiene between patients and change gloves is important

to prevent the VAP

151 87.3 19 95.0 0.313 99 85.3 62 92.5 9 90.0 .345 123 89.9 47 83.9 0.255

Prone positioning intermittently may

prevent VAP and recommended

78 45.1 6 30.0 0.198 45 38.8 36 53.7 3 30.0 0.098 66 48.2 18 32.1 0.041

Using selective oral or digestive

decontamination to reduce risk VAP

125 72.3 11 55.0 0.109 79 68.1 51 76.1 6 60.0 0.393 99 72.3 37 66.1 0.392

Care bundles may be useful in reducing

VAP

137 79.2 18 90 0.250 92 79.3 57 85.1 6 60.0 0.162 113 82.5 42 75.0 0.236

4.7 Conti, Comparison of Nurses` Educational Degree, Years of ICU Experience and Previous VAP Education with Knowledge on prevention of

VAP (N=193)

23

Comparison of nurses` educational degree, years of ICU experience and previous VAP education with knowledge on prevention of VAP is

shown in is table 4.7. There were statically insignificant differences in majority of the items (P>0.05). In the present study, results that reveled

two there were statistically significant differences only in a few items. Regarding the educational levels; nurses with bachelor degree education

had higher knowledge rates on prevention of VAP in terms of “Benzodiazepines should always be preferred to manage agitation” (45.7%),

“Pairing spontaneous breathing trials with spontaneous awakening trials is not necessary” (38.2%) and “Closed/in-line endotracheal suctioning

reduce the risk of VAP” (76.9%) items than the master degree group (P< 0.05). However in “Ultrathin polyurethane endotracheal tube cuffs

may lower VAP rates” item, master degree group had higher knowledge rates (60.0%) than the nurses with bachelor degree (34.1%) (P< 0.05).

It was determined that, there were statistically significant differences between nurses who had <=5 years and 6-10 years of ICU experience,

and the nurses who had >=11 years of ICU experience in a few items (P< 0.05). Nurses with <=5 and 6-10 years of experience had higher

correct knowledge rates than the >=11 group in terms of “If possible, intubation should be avoided to prevent VAP”, “Ultrathin polyurethane

endotracheal tube cuffs may lower VAP rates” and “Kinetic beds reduce the risk of VAP and recommended” items (P< 0.05). However in

“Elevating the head of the bed to 30–45 is important in prevention of VAP” item, >=11 group had higher knowledge rates (100 %) than the

other groups (P< 0.05). There were also statistically significant differences in terms of previous VAP education (P< 0.05). Nurses who had

previous VAP education had higher correct knowledge rates than the other group in terms of “Regular oral care with chlorhexidine is necessary

to prevent VAP” (92.0%), “Ultrathin polyurethane endotracheal tube cuffs may lower VAP rates” (43.1%), “Closed/in-line endotracheal

suctioning reduce the risk of VAP” (78.8%) and “Prone positioning intermittently may prevent VAP and recommended” (48.2%) items.

24

Nurses ` Barriers to Adherence to

VAP Prevention Guidelines

(Statements)

Educational Degree

P value

Years of ICU Experience

P

value

Previous VAP Education

P

value

Bachelor Master <=5 6-10 >=11 Yes No

Always Always Always

N % N % N % N % N % N % N %

Lack of VAP prevention knowledge 65 37.6 8 40.0 0.832 45 38.8 26 38.8 2 20.0 0.490 47 34.3 26 46.4 0.115

Lack of educational programs on VAP

such as in-service education or courses 65 37.6 9 45.0 0.518 41 35.0 30 44.8 3 30.0 0.385 55 40.1 19 33.9 0.420

Shortage of staff in the ICU 94 54.3 13 65.0 0.364 63 54.3 41 61.2 3 30.0 0.167 77 56.2 30 53.6 0.738

Lack of equipment such as gloves and

face masks 30 17.3 4 20.0 0.768 17 14.7 15 22.4 2 20.0 0.408 28 20.4 6 10.7 0.108

Lack of written VAP protocol in the hospital

39 22.5 5 25.0 .804 25 21.6 17 25.4 2 20.0 0.819 31 22.6 13 23.2 0.930

Forgetting to practice the sterile

technique 40 23.1 4 20.0 0.753 25 21.1 17 25.4 2 20.0 0.819 30 21.9 14 25.0 0.641

Lack of time to deliver proper infection

control 37 21.4 7 35.0 .169 25 21.6 17 25.4 2 20.0 0.819 32 23.4 12 21.4 0.772

Hospital system insufficiencies 49 28.3 5 25.0 0.754 26 22.4 24 35.8 4 40.0 0.103 39 28.5 15 26.8 0.813

Comparison of nurses` educational degree, years of ICU experience and previous VAP education with nurses’ barriers to adherence to VAP

prevention guidelines is shown in table 4.8. It was determined that there were no statically significant differences between items and descriptive

characteristics (P >0.05).

Table 4. 8 Comparison of Nurses` Educational Degree, Years of ICU Experience and Previous VAP Education with Nurses ` Barriers to Adherence to VAP

Prevention Guidelines (N=193)

25

5. DISCUSSION

The aim of this study was determination of critical care nurses’ knowledge on

prevention of ventilator associated pneumonia and barriers of adherence to preventive

measures.193 volunteer nurses with different age, educational level and experience

participated in this study.

Regarding to descriptive characteristics of the nurses on VAP education, it was

determined that, the majority of the nurses had received VAP education and more than one

third of them received the VAP education by courses. Participants rated the quality of the

VAP as excellent, very good, good, fair and poor and the most frequent answer was good.

However, majority of participants mentioned that they need education on VAP to improve

nursing skills and enhance patient's outcomes. This result is satisfying in terms of showing

their willingness to improve themselves. Training activities and evidence-based guidelines

and protocols in the ICUs improve the quality of nursing care and narrow the gap between

scientific knowledge and actual performance and form basis for nurses to make the right

decision. In the same line, in our survey more than two third of the participants reported

that there are guidelines and or protocols on prevention of VAP in hospital during their

work experience.

Examination of general knowledge of the nurses on VAP showed that, a majority of

the nurses had correct answers in majority of the items (5 of 6 items). The majority of the

nurses had correct answers for "Continuous education to ICU nurses on prevention of

nosocomial infection is associated with decreased rates of VAP" (T), "VAP is cause of

highest mortality rate among nosocomial infections" (T) and “The Ventilator Associated

Pneumonia (VAP) is pneumonia that occurs > or equal 48 hours after endotracheal

intubation” items. Percentages of the correct answers and wrong/I don’t know answers of

the nurses were close together in "Automated control of endotracheal tube cuff pressure is

important because it decrease the risk for VAP" (T) item. There are same line studies in the

relevant literature; VAP is described in the literature as an infection of the lung that occurs

48 hours after insertion of an endotracheal tube (Rodrigues et al, 2017). There is significant

increase in the rate of VAP resulted with mortality (Porhomayon et al, 2017). In Jordan, a

rate of 29 cases per 1,000 ventilator-days, and the rate of mortality related to VAP as 53%

was determined (Samrah et al, 2016).

26

Another study reported that continuous control of pressure cuff is associated with a

decrease of micro aspiration and VAP (Nseir et al, 2011). Zeinab Hassan et al

recommended continuous education programs about ventilator-associated pneumonia for

nurses in Jordan (Hassan et al, 2016).

In the current study, regarding to nurses` knowledge on prevention of VAP results

showed that, majority of the nurses had correct answers in majority of the items (19 of 24

items) and this is satisfying result. The highest correct answers were “Changing the

ventilator circuit regularly is necessary to prevent VAP”, “Early exercise and mobilization

may increase the possibility of VAP”, “Adequate hand hygiene between patients and

change gloves is important to prevent the VAP”, "Proper sterilization and disinfection of

respiratory care equipment is important to prevent VAP" (T), "Sedation should be

interrupted daily to prevent VAP" (T) and “Care bundles may be useful in reducing VAP”

items. There are studies in the relevant literature supporting our results. A descriptive,

cross-sectional study conducted with 205 ICU nurses to investigate knowledge, attitudes

and practices of nurses about oral care of intubated patients found that, higher scores on

oral care knowledge were associated with performing oral care (Lin et al. 2011). Improved

oral care is necessary and contributes to reduce the incidence of VAP. An observational

study by Llaurado-Serra et al (2014) concluded that, patients connected with endotracheal

tube and without head-of-bed elevation had increased incidence of complications. The

Spanish ‘‘Zero-VAP’’ bundle emphasize that the use of gloves does not preclude the

obligation of hand-washing before and after management of the artificial airway (Lerma et

al. 2013). National Infection Control Guidelines (2016, Singapore) emphasize that patients

undergo mechanically ventilated for >48 hours, a daily sedation vacation and assessment

for readiness-to-extubate is undertaken, early extubation decreases the time spent on

mechanical ventilation and directly reduces the risk of VAP. A study conducted by

Mogyoródi et al (2016) showed a reduction in the incidence and risk of VAP after the

implementation of the bundle that similar to our results. In the present study, most frequent

wrong /I don’t know answers were in “It is necessary to assess readiness to extubate of the

patient daily to prevent VAP”, “Ultrathin polyurethane endotracheal tube cuffs may lower

VAP rates” and “It is necessary to manage patients without sedation whenever possible to

prevent VAP”. However, CDC recommends assessing readiness to extubate once a day

(spontaneous breathing trials) in patients without contraindications (CDC, 2014).

27

Using the endotracheal tube with polyurethane material results in reducing ventilator-

associated pneumonia compared to ETT with Polyvinyl Chloride (PVC) cuff

(Mahmoodpoor et al 2013). Regarding the barriers of the nurses on adherence to VAP

prevention guidelines, present study showed that majority of the nurses had "sometimes"

answers for the barriers to adherence to VAP prevention guideline.

Highest “sometimes” answers were “Lack of educational programs on VAP such as

in-service education or courses”, “Lack of time to deliver proper infection control”,

“Forgetting to practice the sterile technique” and “Lack of VAP prevention knowledge”

respectively. Most frequent "always" answer was "Shortage of staff in the ICU". These

results show similarity results of the study of Jordan et al (2014). The authors notice lack

of time, probably because of the small number of staff at the ICU, the main barrier.

Enough number of nurses in ICUs and professional teamwork reflect nursing

performance. Jansson et al (2013) emphasized that, educational programs and guidelines

as well as ventilator bundles and instruments should be developed and updated to improve

practice and reduce barriers.

Low frequencies in majority of the "never" answers were determined and this result

is unsatisfying. Most frequent "never" answer was "Lack of equipment such as gloves

and face masks” This result shows similarty with the results of the study conducted in

Saudi Arabia. They determined that "Not wearing personal protective equipment" was

not considered as a barrier by majority of the nurses (62.4%) (Yaseen et al 2015).

In comparison of nurse's educational degree, years of nursing experience and

previous VAP education with general knowledge and VAP prevention, results showed

statistically significant differences only in a few items (P< 0.05). There wasn’t

statistically significant differences between descriptive characteristics and items on

barriers to adherence to VAP prevention guidelines statements (P>0.05). Results of the

current study showed statistically significant differences in terms of educational levels

and experiences of the nurses. Nurses who had previous VAP education had higher

correct knowledge rates than the other group in terms of “VAP is the most prevalent

infection in intensive care units”, “Automated control of endotracheal tube cuff pressure

is important because it decreases the risk for VAP” and “Continuous education to ICU

nurses on prevention of nosocomial infection is associated with decreased rates of VAP”

items (P< 0.05).

28

Same line study conducted in Jordan nurses showed significant improvements in

mean knowledge scores on ventilator-associated pneumonia and preventive measures after

an educational program (p<0.05) (Hassan et al, 2016). Samra et al. (2017) recommend

education and periodic training remain a fundamental process of improving health services.

In comparison of knowledge on prevention of VAP with nurses’

educational degree that shown bachelor degree nurses’ correct knowledge rates

were higher than nurses graduated from master degree in items

“Benzodiazepines should always be preferred to manage agitation”, “Pairing

spontaneous breathing trials with spontaneous awakening trials is not

necessary”, “Ultrathin polyurethane endotracheal tube cuffs may lower VAP

rates” and “Closed/in-line endotracheal suctioning reduce the risk of VAP” (P<

0.05). This was an unexpected result. In contrast to other study was conducted to

objective of evaluation of knowledge, attitude, and adherence of healthcare

workers to evidence-based guidelines for prevention of VAP and exploration of

the barriers of their implementation in clinical practice that report significantly

different between nurse assistants (RAs), nurses (RNs), and shown register

nurses higher than assistant nurses with (P=0.001) Mardani et al (2016).

Regarding to experiences of the nurses, results showed that, nurses with <=5 and

6-10 years of experience had higher correct knowledge rates than the >=11

group in terms of “Automated control of endotracheal tube cuff pressure is

important because it decreases the risk for VAP” items of general knowledge;

“If possible, intubation should be avoided to prevent VAP”, “Ultrathin

polyurethane endotracheal tube cuffs may lower VAP rates” and “Kinetic beds

reduce the risk of VAP and recommended” items of prevention knowledge (P<

0.05). Nurses with less experience showed higher knowledge rates than the

nurses who had more experienced. This result may be resulted from being newly

graduated and to remember the knowledge easily. Conversely, Yaseen et al

showed that more experienced nurses performed significantly better rates of

VAP prevention knowledge than their less experienced colleagues (p<0.05)

(Yaseen et al 2015).

29

6. CONCLUSION

Results of the present study showed that, the majority of the nurses had received VAP

education and perceived the quality of the education as “good”; however they have stated

that they need education on VAP to improve nursing skills and enhance patient's outcomes.

This result may be resulted from weakness of quality of the VAP education and is important

in terms of showing the willingness of the nurses for education and development.

Results of the present study showed high level of knowledge on general VAP

knowledge and VAP prevention and this is a satisfying result. Regarding to barriers of

nurses to adherence to VAP prevention guidelines, there were high rates of “sometimes”

and “always” and low rates of the “never” answers. Frequent rated barriers were “Lack of

educational programs on VAP such as in-service education or courses”, “Lack of time to

deliver proper infection control”, “Forgetting to practice the sterile technique” and “Lack

of VAP prevention knowledge” and "Shortage of staff in the ICU". This condition may

inhibit for stuff improvement and development; also may prevent from motivations and

increase incidences of VAP complications. Both national and institutional regulations are

necessary to prevent barriers of VAP prevention.

Results of the current study showed statistically significant differences in terms of

previous VAP education, educational levels and experiences of the nurses. Education

remains as a vital process of improving health services. Professional training programs can

affect for well outcome and reflect for inpatients services. It is necessary to give the chance

of education to the nurses with higher opportunity to achieve and exposure to professional

new in-service education related VAP (Akın et al, 2014). Recommend implementing

multifaceted educational programmers comprising information on recent VAP prevention

guidelines in the general intensive care unit and promoting nurses’ participation to

maximize awareness of infection control.

31

7. FINDINGS AND RECOMMENDATIONS

7.1. Findings

Main findings of the study that was performed with the aim of determination

of the knowledge on prevention of ventilator associated pneumonia and

barriers of adherence to preventive measures of the critical care nurses were

listed as followings:

A total of the nurses of participants in this study 193, the mean of ages of the

participants were 28.4 and the 26-30 group of age was the most frequent (56.5%).

Females were the majority of the participants (60.1%). Most of the participants have

bachelor's degree (89.7%). Majority of the nurses have experience less than five years

as a registered nurses (60.1%). (Table 4.1)

Regarding to general knowledge of the nurses on VAP it was found that; majority of

the nurses had correct answers in majority of the items (5 of 6 items). The most

frequently known items were "Continuous education to ICU nurses on prevention of

nosocomial infection is associated with decreased rates of VAP" (T) (88.6%), "VAP

is cause of highest mortality rate among nosocomial infections" (T) (86.5%) and “The

Ventilator Associated Pneumonia (VAP) is pneumonia that occurs > or equal 48 hours

after endotracheal intubation” (81.3%) respectively. (Table 4.3)

About nurses` knowledge on prevention of VAP; the highest correct answers were in

“Elevating the head of the bed to 30–45 degree is important in prevention of VAP”

(89.6%), “Regular oral care with chlorhexidine is necessary to prevent VAP” (88.1%),

“Adequate hand hygiene between patients and change gloves is important to prevent

the VAP” (88.1%), "Proper sterilization and disinfection of respiratory care equipment

is important to prevent VAP " (T) (87.6%), " It is necessary to assess readiness to

extubate of the patient daily to prevent VAP " (T) (85.0%) and “Care bundles may be

useful in reducing VAP” (80.3%) items respectively. (Table 4.4)

It was determined that, majority of nurse had "sometimes" answer for the barriers

nurses to adherence to VAP prevention guideline. Most frequent "always" answer was

"Shortage of staff in the ICU" (55.4%). Highest “sometimes” answers were “Lack of

educational programs on VAP such as in-service education or courses”, “Lack of time

to deliver proper infection control” (55.4%),“Forgetting to practice the sterile

31

technique” (54.4%) and “Lack of VAP prevention knowledge” (53.9%) respectively.

(Table 4.5)

There were statistically significant differences between correct answers of some items

on general knowledge on VAP and years of ICU experience and previous VAP

education. (Table 4.6)

Regarding the educational levels; there were statically insignificant differences in

majority of the items (P>0.05). In the present study, results that reveled two there

were statistically significant differences only in a few items. (Table 4.7)

Comparison of nurses` educational degree, years of ICU experience and previous VAP

education with nurses’ barriers to adherence to VAP prevention guidelines is shown

in table 4.8. It was determined that there were no statically significant differences

between items and descriptive characteristics (P >0.05).

7.2 Recommendations

Based on the result of this study following recommendations were made:

Continues education programs are necessary to improve nurses’ knowledge

on VAP prevention.

Following and implementation the new guidelines and protocols on VAP

prevention.

National and institutional regulations are necessary to prevent barriers of

VAP prevention.

Further experimental studies related to educational interventions for nurses

may be useful for evidence-based practices.

32

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41

APPENDIX 1 Critical Care Nurses’ Knowledge on Prevention of Ventilator

Associated Pneumonia (VAP) and Barriers of Adherence to Preventive

Measures.

1. Characteristics of Nurse Participants

Subject Number:

1.Age

2.Gender □ Male □ Female

3.Education □ High school

□ Master degree

□ Bachelor’s

□ PhD

4.Working experience

in the ICU (As

years)

5.Number of beds in

ICU

6.Previous VAP

education

□ Yes □ No

7. (If you answered

the item 6 as “yes”)

Educational

resource

□ School

□ Courses

□ Web resources

□ In-service education

□ Congress/conferences

□ Other

8. (If you answered

the item 6 as “yes”)

Perceived quality

of the VAP

education

□ Excellent □ Very good

□ Good □ Fair

□ Poor

9.Need for education

on VAP

□ Yes □ No

10.Is there any

protocol in

hospital for

prevention of

VAP

□ Yes □ No

42

3. Nurses 'Barriers to Adherence to VAP Prevention Guidelines

Statements about barriers Always Sometimes Never

1.Lack of VAP prevention knowledge

2.Lack of educational programs on VAP

such as in-service education or courses

3. Shortage of staff in the ICU

4. Lack of equipment such as gloves and

face masks

5.Lack of written VAP protocol in the

hospital

6. Forgetting to practice the sterile

technique

7. Lack of time to deliver proper infection

control

8. Hospital system insufficiencies

43

2. Nurses’ Knowledge on VAP Prevention

I Don't know False True Statements about VAP prevention No

The Ventilator Associated Pneumonia (VAP) is

pneumonia that occurs > or equal 48 hours after

endotracheal intubation(T)

1

VAP is cause of highest mortality rate among nosocomial

infections (T)

2

VAP is the most prevalent infection in intensive care

units (T)

3

If possible, intubation should be avoided to prevent VAP

(T)

4

Whenever feasible, noninvasive positive pressure

ventilation should be used to prevent VAP (T)

5

It is necessary to manage patients without sedation

whenever possible to prevent VAP(T)

6

Benzodiazepines should always be preferred to manage

agitation (F)

7

Sedation should be interrupted daily to prevent VAP(T)

8

It is necessary to assess readiness to extubate of the

patient daily to prevent VAP (T)

9

Pairing spontaneous breathing trials with spontaneous

awakening trials is not necessary (F)

10

Minimizing pooling of secretions above the endotracheal

tube cuff is necessary to prevent VAP(T)

11

Changing the ventilator circuit regularly is necessary to

prevent VAP (F)

12

Elevating the head of the bed to 30–45 is important in

prevention of VAP(T)

13

Early exercise and mobilization may increase the

possibility of VAP(F)

14

Regular oral care with chlorhexidine is necessary to

prevent VAP(T)

15

44

Proper sterilization and disinfection of respiratory care

equipment is important to prevent VAP (T)

16

Oral route is recommended for endotracheal intubation to

prevent VAP (T)

17

Prophylactic probiotics may be useful to prevent VAP(T)

18

Ultrathin polyurethane endotracheal tube cuffs may

lower VAP rates (T)

19

Automated control of endotracheal tube cuff pressure is

important because it decrease the risk for VAP (T)

20

Saline instillation before tracheal suctioning may cause

to VAP (F)

21

Mechanical tooth brushing may be useful in prevention

of VAP (T)

22

Over feeding a ventilated patient is associated with

increased the risk for VAP (T)

23

Closed/in-line endotracheal suctioning reduce the risk of

VAP (F)

24

Kinetic beds reduce the risk of VAP and recommended

(F)

25

Adequate hand hygiene between patients and change

gloves is important to prevent the VAP (T)

26

Prone positioning intermittently may prevent VAP and

recommended (F)

27

Using selective oral or digestive decontamination to

reduce risk VAP (T)

28

Continuous education to ICU nurses on prevention of

nosocomial infection is associated with decreased rates

of VAP (T)

29

Care bundles may be useful in reducing VAP (T) 03

45

APPENDIX 2 King Abdullah University Hospital Ethical Approval form

46

APPENDIX 3 Islamic Hospital Ethical Approval Form

47

APPENDIX 4 Ethical Approval Near East institutional Reviews Board

48

APPENDIX 5 INFORMED CONSENT FORM FOR ADULTS

You are invited to participate in a research study conducted by Prof. Dr. Nurhan Bayraktar

and Moath Alkhazali, from the Near East University Faculty of Health Sciences, Nursing

Department. This study was planned to determinate the knowledge and prevention and barriers

prophylaxis among nurses. You were selected as a possible participant in this study, because

findings of the study may be useful in improving nurses’ awareness and preventing this important

public health problem. If you decide to participate, a questionnaire will be used as data collection

tool in this study. The questionnaire contains questions regarding for demographics, knowledge and

barriers of nurses on VAP prevention with 3 choices (true,false,i dont know). However, I cannot

guarantee that you personally will receive any benefits from this research. Any information that is

obtained in connection with this study and that can be identified with you will remain confidential

and will be disclosed only with your permission or as required by law. Subject identities will be

kept confidential by don’t using the name, and using participant coding. Your participation is

voluntary. Your decision whether or not to participate will not affect your relationship with Near

East Hospital. If you decide to participate, you are free to withdraw your consent and discontinue

participation at any time without penalty. If you have any questions about the study, please feel free

to contact [05488236500-moath-ke@hotmail.com].[05338398451 nurhan.bayraktar@neu.edu.tr].

If you have questions regarding your rights as a research subject, please contact the Near East

Institutional Review Board. You will be offered a copy of this form to keep. Your signature

indicates that you have read and understand the information provided above, that you willingly

agree to participate, that you may withdraw your consent at any time and discontinue participation

without penalty, that you will receive a copy of this form, and that you are not waiving any legal

claims.

Participant Name, Surname:

Address:

Phone:

Signature:

Witness

Name, Surname: Address:

Phone:

Signature:

Interviewer:

Name, Surname:

Address: